Research Spotlight

Keller, D. S., J. W. Ho, A. J. Mercadel, G. O. Ogola and S. R. Steele (2018). “Are we taking a risk with risk assessment tools? Evaluating the relationship between NSQIP and the ACS risk calculator in colorectal surgery.” Am J Surg Jul 19. [Epub ahead of print].E

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GOAL: To evaluate the relationship between the ACS Risk Calculator and NSQIP expected outcomes in elective colorectal resections. METHODS: The 2015 NSQIP morbidity report for elective colorectal procedures at a single institution was evaluated. Risk Calculator (RC) reports were completed for predicted risk. Correlation coefficients were calculated for the general relationship between the tools for complications. Receiver operator characteristic (ROC) curves compared the predictive accuracy of the tools to actual outcome measures of any complication, serious complications, readmissions, unplanned return to the operating room, and mortality. RESULTS: There was high correlation between NSQIP and the RC for any complication, but low correlation for serious complications. Predictive accuracy of both tools for identifying actual occurrences was poor, with area under the ROC<0.60 for all metrics with both tools, except NSQIP mortality, which had good accuracy. CONCLUSIONS: The tools were highly correlated for predicting complications in general, but neither was accurate for predicting actual outcomes. As underestimating risk and complications could have financial implications under value-based care, refinement could benefit informed consent and quality improvement at the institutional level.

Jarvholm, S., A. M. Warren, M. Jalmbrant, N. Kvarnstrom, G. Testa and L. Johannesson (2018). “Preoperative psychological evaluation of uterus transplant recipients, partners, and living donors: suggested framework.” Am J Transplant Jul 30. [Epub ahead of print].

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Uterus transplantation has become a real option for women with uterine-factor infertility to become pregnant and give birth. The screening prior to uterus transplantation consists of a multidisciplinary evaluation and includes the potential recipient, living donor, and to some extent the recipient’s partner and future co-parent. The psychological evaluation has evolved from broad-based screening in the first uterus transplantation trial, where the aim was to find suitable candidates for a novel experimental procedure with an unknown outcome, to a more directed screening with specific psychological domains for a complex infertility treatment with promising results. This paper outlines a consensus by investigators with pioneering experience in the field of the key factors and suggests a framework for psychological evaluation of recipients and their partners as well as for live uterus donors prior to uterus transplantation. We identify the main areas of particular value to the recipient screening (general psychological health, factors associated with infertility, and medication adherence), the partner (general psychological health and factors associated with infertility), and the living donor (psychological health and motivation to donate, especially in the case of the nondirected donor).

Hebeler, K. R., H. Baumgarten, J. J. Squiers, J. Wooley, B. D. Pollock, C. Mahoney, G. Filardo, B. Lima and J. M. DiMaio (2018). “Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement.” Ann Thorac Surg Jul 23. [Epub ahead of print].

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BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using 4 markers (gait speed, handgrip strength, serum albumin, and Katz activities of daily living). Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), frailty, and/or sarcopenia metrics for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 (13.4%) deaths occurred by 1-year. STS-PROM alone was poorly predictive of 1-year mortality (AUC 0.52, 95%CI: 0.42, 0.68). Only the model including both sarcopenia and all frailty markers (AUC 0.61, 95%CI: 0.53, 0.68) significantly improved predictive ability compared to STS-PROM alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p=0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes following TAVR.

Gomez-Hoyos, J., R. L. Martin and H. D. Martin (2018). “Current Concepts Review: Evaluation and Management of Posterior Hip Pain.” J Am Acad Orthop Surg Aug 3. [Epub ahead of print].

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Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient’s hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Gomes, L. R., L. H. Soares Cevidanes, M. R. Gomes, A. Carlos de Oliveira Ruellas, D. P. Obelenis Ryan, B. Paniagua, L. M. Wolford and J. R. Goncalves (2018). “Three-dimensional quantitative assessment of surgical stability and condylar displacement changes after counterclockwise maxillomandibular advancement surgery: Effect of simultaneous articular disc repositioning.” Am J Orthod Dentofacial Orthop 154(2): 221-233.

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INTRODUCTION: In this study, we quantitatively assessed 3-dimensional condylar displacement during counterclockwise maxillomandibular advancement surgery (CMMA) with or without articular disc repositioning, focusing on surgical stability in the follow-up period. METHODS: The 79 patients treated with CMMA had cone-beam computed tomography scans taken before surgery, immediately after surgery, and, on average, 15 months postsurgery. We divided the 142 condyles into 3 groups: group 1 (n = 105), condyles of patients diagnosed with symptomatic presurgical temporomandibular joint articular disc displacement who had articular disc repositioning concomitantly with CMMA; group 2 (n = 23), condyles of patients with clinical verification of presurgical articular disc displacement who had only CMMA; and group 3 (n = 14), condyles of patients with healthy temporomandibular joints who had CMMA. Presurgical and postsurgical 3-dimensional models were superimposed using voxel-based registration on the cranial base. Three-dimensional cephalometrics and shape correspondence were applied to assess surgical and postsurgical displacement changes. RESULTS: Immediately after surgery, the condyles moved mostly backward and medially and experienced lateral yaw, medial roll, and upward pitch in the 3 groups. Condyles in group 1 showed downward displacement, whereas the condyles moved upward in groups 2 and 3 (P